4.1 Oral Examination
The dentist should assess each patient’s risk for disease and disease progression and should plan treatment accordingly (see the caries risk classification table). While collecting information, the dentist will begin gaining a sense of the patient’s caries activity and compliance with past treatment recommendations. It is important to pay attention to the patient’s health concerns and complaints (if any). This information will help the dentist formulate a diagnosis and treatment, determine the patient’s risk level, and set an appropriate recall interval. Every dentist should have a routine for eliciting and recording information about factors that modify a patient’s risk for disease. Standard dental and medical history forms often do not include questions on diet, fluoride exposure, family oral health history, frequency of dental visits, and oral hygiene practices. The dental office or clinic may need to modify standard forms or create their own. The visual caries examination focuses on detecting both cavitated lesions and subtle changes in enamel quality, which may indicate incipient lesions. When the visual examination is complete, bitewing X-rays can be used to confirm interproximal lesions, document incipient interproximal lesions, and confirm pit-and-fissure lesions. |
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A thorough oral examination includes an evaluation of the patient’s medical history, general health status, dental history, soft and hard tissues, orthodontic status, temporomandibular joint, periodontal health, and prostheses, as well as a caries assessment.
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